Sectoral responses: Health

Health systems include ‘all organisations, people and actions whose primary intent is to promote, restore, or maintain health’.+Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action (Geneva: WHO, 2017) (www.who.int/healthsystems/strategy/everybodys_business.pdf). Urban health systems represent a complex mix of the built environment and social processes, both formal and informal. City health systems include costly healthcare infrastructure and services, which can be seriously affected by disasters and conflict. Investment in the health sector is expensive, and when losses are substantial they can take years to recover.

Many people affected by conflict and disaster may have limited access to healthcare. Emergencies can cause disruption and strain due to infrastructure damage, loss of medical equipment and health staff and increased demand for services. Finally, baseline deficits in public health infrastructure and the physical and social determinants of health in rapidly growing cities may present a pre-existing health emergency even prior to a disaster or conflict.

This section+This section benefited in particular from the inputs of Dr Ronak Patel, Clinical Assistant Professor of Emergency Medicine, Stanford University. reviews health in urban emergencies. It discusses urban healthcare provision, and the role of cash and markets in health during urban crises. Health and forced displacement in urban areas is discussed. This section links to a number of others in this Good Practice Review, in particular food security (Section 4.9) and cash (Section 3.3).

4.8.1 Health in urban emergencies

Different emergencies will result in differing needs. For instance, an earthquake causes immediate crush injuries and other related effects (see Table 4.4), while conflict will add penetrating wounds from bombs or gunshots and, for many, longer-term mental health disorders (referred to below). According to the World Health Organization (WHO),+WHO, Technical Report: Health Systems in Urban Disasters, 2013 (https://extranet.who.int/kobe_centre/en). the health impacts of urban disasters can be organised into four broad categories:

Communicable diseases, exacerbated by population movements and overcrowding.
Non-communicable diseases (NCDs), including lifestyle diseases (such as hypertension and obesity) and conditions needing long-term care (such as kidney disease requiring dialysis), exacerbated by disrupted access to medications.
Mental health and psychosocial (MHPSS) disorders, created or exacerbated by trauma.
Trauma due to external causes, such as falling buildings or electrocution.

Similarly, one review+C. Deola and R. Patel ‘Health Outcomes of Crisis Driven Urban Displacement: A Conceptual Framework’, Disaster Health 2(2), 2014 (www.ncbi.nlm.nih.gov/pubmed/28229003). identifies the generalised health consequences of urban crises:

Infectious pathogens can spread more easily given population movements and density, low vaccination coverage and compromised herd immunity, along with inadequate capacity to detect and respond to outbreaks.
Underlying poor health from malnutrition, frequent illnesses, inadequate access to care and baseline deficits in water, sanitation and public health infrastructure can all be exacerbated.
Mental health needs increase directly from post-traumatic stress disorder (PTSD), depression and anxiety, alongside disruption to prior support and care systems.
Increased trauma and injury, including from higher rates of urban violence.
Gender-based violence may increase.
Chronic diseases can be exacerbated by disruptions in care, leading to acute medical crisis.

Table 4.4 gives examples of health needs resulting from two earthquakes.

Table 4.4 Individual health needs

Source: WHO, Technical Report: Health Systems in Urban Disasters, 2013 (https://extranet.who.int/kobe_centre/en), p. 23.

The Sphere Project’s 2018 revision notes that identifying people at risk+See also WHO, Rapid Risk Assessment of Acute Public Health Events, 2012, (http://apps.who.int/iris/bitstream/handle/10665/70810/WHO_HSE_GAR_ARO_2012.1_eng.pdf?sequence=1). and who may not have access to healthcare poses particular challenges:

people seeking refuge in towns and cities often do not have information about existing health services or how to access them, risking a further increase in communicable diseases. Outreach will help people cope with new urban stresses such as inadequate access to shelter, food, healthcare, jobs or social support networks.+Sphere Project, The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response, 2018 (https://handbook.spherestandards.org/), chapter 8.

The revision also notes that ‘Rumours and misinformation spread quickly in cities’. This was a particular issue in the West Africa Ebola response; as one study by ALNAP explains:

Much of the initial communication [around Ebola] was dramatic and negative: ‘Ebola kills’, ‘There is no cure’ and ‘Don’t touch’ … The public, not understanding, responded in panic, hiding sick relatives, reporting fewer cases and spreading misinformation. Several interviewees shared anecdotes of community members who saw neighbours taken to a

treatment unit who never came back. Humanitarians often failed to understand that, where their communications did not address people’s concerns, rumours and misinformation would be likely to fill the gap.+L. Campbell and L. M. Morel, Learning from the Ebola Response in Cities: Communication and Engagement (London: ALNAP/ODI, 2017) (www.alnap.org/system/files/content/resource/files/main/alnap-urban-2017-ebola-communicationcommunity-engagement.pdf), p. 13.

In Sierra Leone, ‘rumours spread that the government was using Ebola for political gains. In 2015, research found that only 50% of those surveyed in Freetown considered the government trustworthy, compared with 70% of the population outside the Freetown capital area’.+P. Richards et al., Community Cohesion in Liberia: A Post-war Rapid Social Assessment (Washington DC: World Bank, 2013), cited in ibid.

For further discussion of public health crises in cities, see Cities and Public Health Crises, Report of the International Consultation, 29–30 October 2008, Lyon, France, 2009 (www.who.int/ihr/lyon/FRWHO_HSE_IHR_LYON_2009.5.pdf?ua=1).

4.8.2 Urban healthcare provision in terms of health systems

WHO+WHO, Technical Report: Health Systems in Urban Disasters. emphasises the need to understand urban healthcare in terms of systems,+See also ‘Measuring Urban Capacity for Humanitarian Crises: Piloting an Urban Health Response System Assessment Tool (UHRSAT)’ (www.elrha.org/project/measuring-urban-capacity-humanitarian-crisis-piloting-urbanhealth-response/). comprising six inter-related sub-systems – governance, health financing, health workforce, service delivery, essential medicines and technology and health information systems. Recommendations include:

A systems approach helps at all stages of the project management cycle, including assessment, monitoring, documentation and evaluation.
The recovery phase provides an opportunity to advocate for better policies and planning.
A critical area that needs strengthening in emergencies is health information management, for example disease surveillance, coordination and patient records management.
Linked to the last point, external agencies needs to be cognisant of existing systems and their structures (see the case study in Box 4.23).
Rigorous evaluations of health systems can be ‘a policy window for health systems development’.

Box 4.23 Health response on Luzon island to the 2009 Philippines typhoons

Three typhoons ravaged Luzon island in the northern Philippines in September and October 2009. The metropolitan area affected comprised more than 10 cities.

‘During the emergency, national and local governments and hospitals activated their emergency response plans and organized their incident command systems. There was strong national and local government lead response although most information available was from the national government perspective. The delineation of national and local government roles was well documented. The Philippines implemented a national version of the global cluster system where different sectors/needs were divided into focus areas (clusters) led by the government. Strong coordination was achieved between national and local governments (different levels), different sectors and government and non-government through the clusters. On the other hand, there were challenges in integrating national and international response coordinating mechanisms. Clusters were also organized at the local level. Some local governments had strong capacity in preparedness and response because of strong political will and prior planning. The local health sector is a member of the local disaster coordinating body (now disaster risk reduction and management body). Emergency response has been rolled down to the community level through the barangay (village) health emergency response teams. Hospitals had their own network and referral systems. The Philippine experience can give good lessons on how decentralized systems can work.

‘Coordination was challenging within a complex system that was decentralized and with a strong private health sector. Coordination had to be built in different levels and lines – between national and local, between national and international, inter-sectoral and between public and non-government agencies. Coordination at the field level was also a different challenge that should be strengthened. The purpose of the clusters must be clear to partners and its efficiency must be enhanced. Perhaps as a result of decentralization with strong local government units, response efforts have been politicized with possible risks to inefficiency and inadequate access to essential health care and medicines. Some cities had local level contingency and response plans; development and review of these plans must be prioritized. Plans must clearly define the policy shift to emergency mode. The health information system must be strengthened and this includes disease surveillance, assessment and monitoring of needs, sharing of information and documentation. Other response priorities included strengthening of response capacity of the health workforce and regulation of donation practices.’

Source: Quoted from WHO, Technical Report: Health Systems in Urban Disasters, p. 46.

Further information on health systems can be found in UNICEF, Approach to Health Systems Strengthening (New York: UNICEF, 2016) (www.unicef.org/health/files/UNICEF_HSS_Approach_-_8Aug16.pdf). See also WHO, Toolkit for Assessing Health System Capacity for Crisis Management (Copenhagen: WHORegional Officefor Europe, 2012) (www.euro.who.int/__data/ assets/pdf_file/0008/157886/e96187.pdf); and WHO, Health Systems in Urban Disasters (www. who.int/kobe_centre/emergencies/Health-systems-in-urban-disasters_2013.pdf?ua=1). See also several recent studies from Elhra that explore ‘what works’ when providing public health services during humanitarian crises (see www.elrha.org/news/eight-new-studies-on-providing-public-health-services-during-humanitarian-crises/).

Section 1.1 on ways of seeing the city provides further discussion of systems.

The case study example from the Philippines in Box 4.23 underscores the importance of a coordinated, systems-based approach to urban emergency health.

4.8.3 Good practice in strengthening health systems

Good practice in this area includes prioritising working through, rebuilding or improving pre- existing healthcare systems as early as possible. Health interventions must be sustainable, and must not be seen purely as short-term life-saving measures built in parallel, as they then undercut existing systems. This can be as devastating as the disaster itself, taking years to recover.

To these ends, humanitarian agencies should prioritise training local healthcare providers for a variety of basic emergency and longer-term mid-level treatment to leave behind greater capacity for primary care. Agencies engaged in humanitarian health interventions should also understand that there really is no such thing as an isolated health emergency: health and the ability to affect people’s health in cities is a function of all the complex and interactive systems within the urban space, including shelter, transport, security and infrastructure.

Humanitarian agencies should be prepared to deal with psychosocial needs, which are often under-addressed before a crisis and compounded afterwards. Agencies should also resource interventions for the longer-term physical and psychological rehabilitation required after immediate healthcare needs are met. As part of the immediate healthcare response, agencies should also implement programmes that include screening for women and children who may be vulnerable to gender-based violence, intimate partner violence, trafficking or exploitation.

For further guidance on mental health, see ‘Mental Health and Psychosocial Support in Humanitarian Crises’, Humanitarian Exchange 72, July 2018 (https://odihpn.org/magazine/mental-health-and-psychosocial-support-in-humanitarian-crises/).

Approaches to assisting rape survivors can be found in WHO, Clinical Management of Rape Survivors: Developing Protocols for Use with Refugees and Internally Displaced Persons (Geneva: WHO, 2014) (http://apps.who.int/iris/bitstream/handle/10665/43117/924159263X.pdf?sequence=1).

4.8.4 Cash, markets and healthcare during urban crises

The Global Health Cluster and WHO+Global Health Cluster and WHO (2018), Working Paper for Considering Cash Transfer Programming for Health in Humanitarian Contexts, 2018 (www.who.int/health-cluster/about/work/task-teams/working-paper-cash-health-humanitarian-contexts.pdf). make the following recommendations concerning the use of cash programming:

Cash assistance is helpful – it can make healthcare affordable.
Cash for health should not replace supply-side health financing, but should complement it.
Minimum quality standards in health provision need to be assured.

Cash is discussed further in Section 3.3.

4.8.5 Health and forced displacement in urban areas

UNHCR’s Operational Guidance on Refugee Protection and Solutions in Urban Areas emphasises the need for a multi-sectoral, holistic approach to refugee health in urban areas: ‘The health status of refugees will not be improved by health services alone; the underlying determinants of health must also be addressed by improving livelihoods and income, food security and nutrition, housing, education and access to water and sanitation services’.+UNHCR, Ensuring Access to Health Care: Operational Guidance on Refugee Protection and Solutions in Urban Areas (Geneva: UNHCR, 2011) (https://cms.emergency.unhcr.org/documents/11982/39268/UNHCR%2C+Operational+guidance+on+refugee+protection+and+solutions+in+urban+areas+%E2%80%93+Ensuring+access+to+health+care/300ef365-188c-4b34-aa32-c00a387ee098), p. 3. To achieve this, UNHCR advocates a ‘three-pronged approach’ of advocacy, support and monitoring and evaluation.

A review of good practice by UNHCR+UNHCR, Designing Appropriate Interventions in Urban Settings: Health, Education, Livelihoods, and Registration for Urban Refugees and Returnees (Geneva: UNHCR, 2009) (www.unhcr.org/4b2789779.pdf). identifies the following key points to consider concerning health provision in urban refugee settings:

The availability of health services (for instance ensuring enough beds for the number of patients anticipated).
Distance to the nearest healthcare facilities.
Financial and legal constraints on accessing health services, including not being registered with UNHCR or not having legal identification documents in the host country.
Cultural and religious sensitivity. This might, for example, mean ensuring separate facilities for female patients and enough female providers for exams.
Giving thought to possible tensions between host and displaced communities with regard to healthcare provision and access, for example overwhelming already burdened facilities with additional patients.
Primary health care and emergency health services need to be free of charge in the initial emergency phase (while taking care not to undermine pre-existing medical payment systems after an emergency).
Refugees from middle-income countries – as in the Syrian crisis – may be older than is typical for refugee populations elsewhere, and may present with chronic diseases.
Urban refugees need to be integrated into existing health services.
Avoid creating parallel health structures.
Urban refugees need to be connected to food and nutrition programmes and the other basics that underlie good health.
Monitoring urban refugees’ health needs and how they are being met can be problematic given the ‘hidden’ nature of urban life, and many people may use more than one health provider. This makes arriving at meaningful data on morbidity within urban refugee populations difficult.

For a discussion on meeting the maternal and newborn health needs of displaced people see the Wilson Center’s Maternal Health Initiative (www.wilsoncenter.org/event/humanitarian-response-urban-settings-meeting-the-maternal-and-newborn-health-needs-displaced). See also UNICEF and Save the Children, Newborn Health in Humanitarian Settings (New York: UNICEF Programme Division, 2016) (www.unicefinemergencies.com/downloads/eresource/docs/Health/NewBornHealthBook-ProductionV17-Web.pdf).

For a discussion of refugee mental health needs in urban areas in Jordan, see MSF, ‘The Less Visible Humanitarian Crisis: Refugee Mental Health Needs in Urban Jordan’, 17 October 2018 (www.msf.org/mental-health-needs-refugees-urban-jordan). These issues are also discussed in D. J. H. te Lintelo and E. Soye, ‘Urban Wellbeing, Mental Health and the Syrian Refugee Crisis’, IDS Opinion, 9 October 2017 (www.ids.ac.uk/opinions/urban-wellbeing-mental-health-and-the-syrian-refugee-crisis/).

In summary, health provision in urban emergencies is complex, with varying timeframes ranging from life-saving action to longer-term provision and care, such as for mental health needs. In protracted emergencies, engaging in healthcare systems is vital, recognising the multi-sectoral, multifaceted and interlinked nature of healthcare provision.

Chapter 4 Sectoral responses

Health